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Insurance Coverage for Infertility Treatment

Last Updated: May 10, 2002
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Insurance Coverage for Infertility Treatment Study your plan to reverse claim denials
By Pamela Prager

Couples who face infertility not only face the emotional pain associated with not being able to have a child, but may also face obstacles put in front of them by their health insurance and employers. The following guidelines are designed to assist couples to overcome some of these obstacles on their own.

However, every situation is different under the law, and an attorney should be contacted for assistance with specific legal problems. Should it be necessary to seek legal advice, the references listed at the end of this article will be of assistance in evaluating your case.

Many insurance carriers do not provide health insurance coverage for infertility, or provide only very limited insurance coverage. If your claims for infertility treatment have been denied, take the following steps:

State Mandates

Determine whether or not you live in a state that has mandates for infertility insurance coverage. There are a handful of states that mandate insurance coverage for infertility to some extent or under certain conditions.

Your Insurance Contract

Read your insurance contract. Most people obtain their health insurance through their employer, who provides a "summary" of the health insurance plan. Although this is helpful to some extent, it is the actual contract which controls your health insurance issues. If you do not have a copy of your contract, ask your employer for a copy. Under the Employees Retirement Income Security Act (ERISA) a federal law which regulates pension and insurance benefits provided to employers to employees, your employer is required to give you a copy.

Insurance contracts are construed against the insurance carrier. Generally speaking, if the contract does not have an exclusion for infertility, the insurance company must pay benefits.

Read your contract to determine if there is a specific exclusion for infertility. If there is not an exclusion, you should have coverage. If there is an exclusion, carefully read what it excludes. Does it exclude treatments only, or does it also exclude diagnosis?

As an example, I recently represented a woman who had a laparoscopy with an incidental chromotubation because of complaints of pelvic pain. The insurance carrier denied the claim stating it was for the treatment of infertility. By taking the claim through the grievance process, eventually the insurance carrier made a determination to pay the benefits. We were able to establish that the laparoscopy was not done for infertility, but for pelvic pain. More importantly, the contract only excluded "treatment" of infertility. Since the procedure was diagnostic, the insurance carrier determined that it was required to make the payment. Thus, it is very important that you determine what is excluded and ultimately the reason the insurance carrier is denying the claim.

Your insurance carrier can only deny benefits for what it has excluded.

Appealing Denials of Claim
If you have read your contract and believe you should have coverage (and your insurance carrier has denied a claim or stated you do not have coverage when preauthorization is requested), write your insurance carrier and ask for identification of the specific reasons for the denial and under what provision of the contract your claim is being denied.

In the past, insurance carriers that do not have exclusions have denied claims for one of the following three reasons:
  1. Infertility is not an illness;
  2. Treatment of infertility is not medically necessary;
  3. Treatment of infertility is experimental.

These are invalid reasons to deny your claim. Infertility is an illness (2). Medically necessary is usually defined by insurance policies as medically required and medically appropriate for diagnosis and treatment of an illness or injury under professionally recognized standards of health care. Treatments such as GIFT, IVF, ZIFT/PROST have NOT been on the American Medical Association's experimental list since the late 1980s.

If the insurance carrier gives another reason, you should review your policy carefully and determine if the reason they give is consistent with the insurance contract.

Once the insurance carrier has identified to you the reasons for the denial of the claim, you can then present evidence to it that its reasoning is incorrect. This may include a letter from your doctor explaining the reasons for a particular procedure. You should also write a letter to the insurance carrier explaining why you believe its denial was inappropriate.

You should attempt to make all contacts with the insurance carrier through written communication. If you should need to contact them by telephone, record the call if possible. If not, take extensive notes, which should include the date and time called, who you spoke with and what was said.

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